Foot reconstruction

Reconstructive foot surgery is a group of surgeries performed on different parts of the foot to provide stability, regain function, and management of pain associated with various foot disorders and deformities.

The bones in the foot, sequentially, from the ankle to the toes are the talus, calcaneus, tarsals, metatarsals, phalanges, and sesamoids. The talus and calcaneus form the ankle and heel, tarsals are in the midfoot, forming the foot arch, sesamoids are in the ball of the foot, metatarsals make the forefoot, and phalanges are in the toes. These bones (two or more) meet to form joints. Each bone end in the joint has cartilage encasing it and a capsule around it, containing fluid. The cartilage and fluid lower the friction when the joints move.

The bones in the foot are connected to one another with the help of ligaments, which hold the bones in position to form the arch of the foot. The ligaments in the foot include the plantar fascia, plantar calcaneonavicular ligament, and calcaneocuboid ligament. The plantar fascia extends from the heel to the toes on the lower side of the foot. It contracts and stretches to help while walking and balancing. Plantar calcaneonavicular ligament is in the sole and supports the talus head, while the calcaneocuboid ligament attaches the tarsals to the calcaneus and helps in supporting the arch of the foot. 

The muscles in the foot give it shape and help in movement. Important foot muscles include the tibialis anterior, tibialis posterior, tibialis peroneal, flexors, and extensors. Flexors and extensors help in moving the toes while taking a step. Tibialis anterior helps in raising the foot, tibialis posterior is at the arch, and tibialis peroneal plays a role in the movement of the outer side of the ankle.

The Achilles tendon in the foot connects the calf and heel. It is the most important tendon and helps in climbing, jumping, running, and even standing on your toes. Tendons are connective tissues that connect the bones and muscles.

Different conditions or diseases, including trauma or congenital defects, may cause a deformity in the foot. In such a case, foot reconstructive surgeries may be recommended. The type of foot reconstruction depends on the underlying defect and some of them include:

• Joint implant
• Tendon transfer/repair
• Bone fusion
• Osteotomy (cutting a part of the bone)
• Lateral column lengthening
• Ankle replacement
• Arthroplasty

Reconstructive foot surgery is indicated in the following conditions:

• Adult-acquired flatfoot deformity
• Diabetic foot conditions such as a bunion, Charcot’s foot, and hammertoes
• Hallux valgus 
• Hallux limitus (foot deformity leading to limited movement of the big toe) and hallux rigidus (rigid big toe)
• Arthritis in the joints that form the foot arch or in the joints of the ankle and foot
• Claw and mallet toes
• Plantar fasciitis
• Bone spurs
• Haglund’s deformity (enlargement of the bone of the back of the heel)
• Problems associated with Achilles tendon (Achilles tendon is contracted)
• Congenital defects such as clubfoot
• Clubfoot that occurs after a midfoot amputation

Common symptoms of foot disorders include pain and difficulty in walking. There may also be some balance issues.

A tendon transfer surgery may not be performed due to the non-availability of a donor. Its relative contraindications (surgery can be performed but with caution) include:

• Low muscle strength
• Stiffness in joints
• Neuromuscular disorder

The contraindications for ankle replacement surgery include:

• Infections 
• Death of the tissues of the talus (ankle bone)
• Charcot’s foot (a condition characterised by gradual weakening of bones and soft tissues of foot)
• Neuromuscular diseases
• Metal allergies

Bone grafting may not be advised in the following conditions:

• Sepsis
• Allergic reaction to anaesthesia
• Previous graft taken from the same site 
• Decompensation (if the organ does not function properly)

The surgery for the treatment of hallux valgus is contraindicated in arterial occlusive disease.

Some common preparations for the reconstructive foot procedures include:

• You will have to share the following details with the surgeon:
  • Your medical history
  • Any allergies that you may have
  • A list of medicines that you take, including over-the-counter medications and herbs
• The surgeon will ask you to undergo a few tests:
  • Blood tests 
  • X-rays 
  • Electrocardiogram (ECG)
  • Magnetic resonance imaging (MRI)
• Women on hormone replacement therapy or those taking oral contraceptives should discontinue them a few weeks before the surgery.
• You may need to stop getting any treatment for your feet at least one week before the surgery and resume only after the surgeon’s consultation.
• If you have any fungal infection in your foot, get it treated before the surgery.
• You should discontinue smoking before the procedure as it may otherwise put you at risk of complications.
• Your surgeon will ask you to fast from the midnight before the surgery. 
• You will have to sign an approval form to grant your permission for the procedure.
• Make sure to arrange for a friend or family member to drive you home following the procedure.

Once you reach the hospital, you will be given a hospital gown to change into, and an intravenous (IV) line will be attached to your arm to administer fluids and medicines during the surgery. The hospital staff will move you to the operating room, and your blood pressure and heart rate will be monitored.

Depending on the type of surgery, you will be given general (a sleep-inducing medicine) or local anaesthesia (numbs the area of operation, but you will be awake). Once the anaesthesia takes effect, the surgeon will place an incision (cut) at the point where the surgery needs to take place. The following steps are performed for different procedures in foot reconstruction surgery.

• Osteotomy: 
  • The surgeon will cut the bones in the affected part of your foot and shape it to correct the damage.
  • He/she will use bone grafts in the area to help the bones to fuse or add length to the outer side of your foot.
  • The surgeon may use plates or screws temporarily to support your bones during healing. 
  • Osteotomy is commonly performed in the midfoot and heel region. 
• Tendon transfer: 
  • The surgeon will remove the damaged tendon and replace it with a tendon from another region in your foot. 
  • If only a part of the tendon is damaged, the surgeon will only remove the diseased part.
  • This surgery helps in forming the arch that was lost in flatfoot. 
• Bone fusion: 
  • The surgeon will take off all the cartilage around the affected bones and put a bone graft in its place. This helps to fuse smaller bones to form one large bone and eliminate joint pain. 
  • Screws, pins, or plates (instrumentation) will be used to provide additional support.
• Triple arthrodesis: This is a bone fusion surgery of three joints present in the hindfoot to form one bone. It is performed with bone grafts and/or instruments. 
• Implant: The surgeon will place a small subtalar implant on the side of your hindfoot to prevent the movement in your ankle bones. The implant will also support your foot arch. This is performed if the talus bone has moved. The implant is kept in place by the tissue that grows around it. 
• Removal of bony prominence: This surgery removes bony outgrowths on the sole. In this case, the bones in the surrounding region are not held very firmly, so the removal of the bony prominence is not possible as the bones can move to form a new prominence. Thus, the surgeon will have to reposition the bones and fuse them to correct this disorder. 
• Internal fixation: In this procedure, the bones in the feet are rearranged. The rearranged bones are held in place with the help of instrumentation (screws and plates) that is removed in a few months.
• Lateral column lengthening:
  • The surgeon will cut the calcaneus bone on the outer edge of your foot. 
  • He/she will insert a metal or bone from an organ donor into the cut bone. This will then be fixed with the help of instrumentation.
  • The procedure helps to add length to the bone for the correction of the foot deformity.
• Ankle replacement: This involves the replacement of the damaged ends of the shin bone (connects knee with the ankle bones) with synthetic ends that may be made of plastic or metal.
• Arthroplasty: Removal of the damaged phalange joints is done with arthroplasty to achieve flexibility between the joints in the toes.

Once the surgery is over, your cut will be covered with a dressing and crepe bandage. The medical staff will then take you to the recovery room, and your foot will be kept elevated. A nurse will give you medicines to relieve pain. You may be discharged on the same day, or need a hospital stay, depending on your condition.

At home, you will need to take care of yourself in the following manner:

• Keep your leg in an elevated position on a pillow for at least two weeks after the surgery to prevent swelling.
• Take the pain medication as prescribed. Generally, the pain reduces if on resting and keeping your foot raised. 
• A special shoe will be given to you that you need to wear over the dressing for six weeks. You may need crutches while walking to prevent putting pressure on your foot. 
• Wait for at least six weeks before you drive.
• You will be advised to apply an ice pack on the operated area to help prevent swelling. Do not use ice directly to the skin as it may damage the area.
• Make sure to keep the dressing and plaster dry all the time. If they get soaked in blood, they need to be changed. 
• Your doctor will tell you if your foot can bear your body weight and how to follow the weight-bearing. It is essential to follow it to let the surgery be successful. Depending on the type of foot surgery, you may have the following types of weight-bearing advised:
  • Non-weight bearing (no weight can be tolerated)
  • Toe touch weight-bearing (your toe may bear a little weight)
  • Heel weight-bearing (your heel can tolerate a little weight)
  • Partial weight-bearing (you may put a little weight on your foot).
• Your physiotherapist will show you different exercises to perform. After some months, with the help of physiotherapy, you will be able to participate in sports. However, activities like swimming that do not require any weight-bearing can be resumed once your incision heals.
• You can resume work, depending on the type of profession. If it is a desk job, you can restart after two weeks, but you will need to keep your foot elevated. However, if your job involves manual labour, it may be up to three months before you resume.

Foot reconstructive surgery reduces pain and helps in walking effectively. However, it is not performed to improve the aesthetic features of the foot.

When to see the doctor?

You may need to see the doctor in the following cases:

• Swelling in the foot 
• Your toes are white or blue
• Increased redness or pain in the foot
• Excess discharge from the incision site
• Fever

Foot reconstruction surgeries carry some of the following risks:

• Infection
• Nerve damage in the foot, causing numbness
• Bones may not fuse
• Surgical scar sensitivity
• Symptoms may not subside
• Deep vein thrombosis
• Damaged blood vessels, causing improper circulation in the foot 
• Bleeding
• Allergy to certain medicines and/or anaesthesia

Your follow-up will be scheduled two weeks after the surgery wherein the doctor may remove the stitches and put a plaster. At the six-week follow-up, your progress will be checked with the help of an X-ray, and the doctor will remove the plaster.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.